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RADIO 4
CURRENT AFFAIRS
ANALYSIS
Failing Better
TRANSCRIPT OF A RECORDED
DOCUMENTARY
Presenter: Michael Blastland
Producer: Helen Grady
Editor: Innes Bowen
BBC
White City
201 Wood Lane
London
W12 7TS
020 8752 7279
Broadcast Date: 22.02.10 2030-2100
Repeat Date: 28.02.10 2130-2200
CD Number:
Duration: 27.37
Taking part in order of appearance:
Simon Brailsford
RAF group captain
Estelle Morris
Former education secretary
Paul Johnson
Formerly senior official in the Treasury and the department of
education
Fraser Nelson
Editor of the Spectator magazine
David Halpern
Former Prime Ministerial advisor
Atul Gawande
Surgeon, writer and Associate Professor at the Harvard School of
Public Health
Susan Wolff
Professor of Philosophy at the University of North Carolina
BLASTLAND: My trade is journalism and we’re a blood-thirsty lot.
We talk about gaffes and cock-ups, the humiliating U-turn. We love
mistakes. We enjoy pursuing people for them and throwing around the
blame. But today we’ve come to RAF Cranwell near Grantham to a
centre of flight-training excellence, where they take a rather different
attitude to mistakes. Some of it is even joking- they talk about leaving
great holes in the ground because here making a mistake makes rather a
difference. The head of safety in the RAF is group captain Simon
Brailsford.
BRAILSFORD: The Air Force is committed to a just culture. When
someone has said they’ve made a mistake, all the issues surrounding
that mistake are thoroughly investigated and, if the mistake was made
genuinely, the individual will be congratulated for reporting it because
he may well have saved that error in future.
BLASTLAND: Watching this plane tumbling through the sky seeing
someone learning how to do things wrong doing in order to get them
right again.
BRAILSFORD: There we go, stalled it, wing over, straight down with a
quick twist in the middle.
BLASTLAND: Breathtaking.
BLASTLAND: The parade of error is everywhere here - anecdotes
posted above every urinal. Black humour mixes with a regime of
checks, evaluation of any false move, and the effort to keep egos on the
ground. Is it for real? It seems so: they have a magazine about cock-ups
with the telling title: Air Clues. How would you characterise attitudes to
mistakes in politics? Vengeful? Perhaps. Prone to cover up and denial,
and as personally vicious as possible? At times, probably. And by the
way, don’t we love it? More from the RAF later. Oh, and there’s an
obscure factual mistake later in this programme. See if you spot it. But
here’s our question. Could those in the world of policy fail better, as the
playwright Samuel Beckett put it? Or, in a fiercely competitive politics,
bedevilled by events, is that hope naive? Certainly, plenty goes wrong.
Here are three examples. First, the out and out disaster, and the
temptation to cover-up, observed by former education secretary, Estelle
Morris.
MORRIS: The biggest I had to deal with, I didn’t set it up. That sounds
terrible; ‘it wasn’t me, gov.’ But was the dealing with the Individual
Learning Accounts. They were a Mistake with a big ‘M’.
BLASTLAND: Individual learning accounts? Where the government
provided vouchers or money for people to buy education or training
from private companies - and were often ripped off.
MORRIS: They were a huge error. I was back in my constituency.
Permanent Secretary rang Friday afternoon. Says the…. I think it was
the police in actual fact. There was massive fraud. “This is a big
mistake and we need to deal with it now.” By the Monday we knew
what we were doing. We were going to collapse the scheme
completely.
BLASTLAND: Was there resistance to the sort of hands up
description?
MORRIS: Yes there was, yes there was. You know somebody - I’m not
going to say who - said, “Look, this was a flagship policy. This isn’t
going to look great. You’ve got options. Close it quietly. Run it down
and then hope that no one asks about it. No-one suggested carrying on
with the fraud - no one suggested that but somebody said; “don’t say
you’re closing it - just change it to make it right.” But that wouldn’t
have been right. I wouldn’t have wanted to handle the implementation
of a policy that I think was structurally and fundamentally flawed.
BLASTLAND: Structurally flawed, says Estelle Morris. Remember
those words as we move to our second example of political error, that
of understanding, perhaps especially when blinded by belief in one’s
own genius. Paul Johnson was formerly a senior official in the Treasury
and the department of education.
JOHNSON: There are the sort of big mistakes like what we’ve seen
with the macro economy, which I would really describe as the
government just not understanding where the economy was relative to
what could reasonably be achieved. And that’s actually a very similar
mistake, interestingly, to the mistake that the treasury made in the
1980s. The belief was that the economy was on trend, doing very well,
unemployment was very low, growth was permanently high, and on
both occasions that proved to be vastly too optimistic.
BLASTLAND: It wasn’t sustainably doing tremendously well. It was
just a bit of a boom or …unsustainably doing very well.
JOHNSON: Yeah, that’s exactly right - it required a kind of belief that
the trend and the way in which the economy goes up and down had just
changed, and had changed you know in a way that it hadn’t changed in
the last hundred years so I think when there are big sort of trend errors,
as it were, when the error is about kind of your whole direction of
policy, then there can be a degree of vanity, a degree of ideological
conviction behind it.
BLASTLAND: It would be surprising if people lacked faith in their
own policy. Paul Johnson argues that what matters is to ensure they are
challenged – a particular problem with the Treasury, which he says is
watchdog over others, but not adequately watched itself. Fraser
Nelson, editor of the Spectator magazine, offers that notorious example
– the poll tax – as a bad case of political momentum that trumped any
challenge.
NELSON: There are a lot of politicians who thrive on being right and if
it turns out that they're wrong in a fairly major way, that their whole
analysis was wrong, then they face this kind of existential crisis really –
that, “if my analysis was wrong, then maybe I’m just the wrong guy in
the wrong job. I’ve just got it all wrong and I should curl under a rock
and hide”. Because people’s authority, their currency is based so much
on their being right and their having the right instinct. If you take the
poll tax, that is a classic study of something which should have been
stopped at a very early stage because initially when they were doing the
calculations, they thought people would be charged a quarter of what
they ended up being charged. It was a fundamental and huge error. As
soon as they worked out people would have to pay large amounts that
everybody would have, and it should have been dropped there and then.
But by that point, it had become a totem of Thatcher’s authority, and if
she were to backtrack on that her authority would be diminished. So
that is why dead horses are flogged as badly as they are in politics; that
very bad ideas are kept on when in fact they should be dropped.
BLASTLAND: Fraser Nelson, on the political fetish for ‘instinct’ that
makes errors of understanding hard to admit, even to oneself. For a
third example of error, how about too much haste, too little evidence
that a policy will work. A tendency observed in ministers by former
Prime Ministerial advisor David Halpern.
HALPERN: Of course ministers want to make a rapid impact. They’re
often not in a post for very long, and if the answer coming back to them
is well we’re not quite sure what will work, let’s try out a few different
things and then let’s figure it out, that’s not a very appealing one. They
want to have a big impact fast. And that can set the conditions for
policy failures in the sense that you’ll move too rapidly, especially to a
national rollout of something which you’re not sure about. So the
political incentives can be stronger on the hand of you must do
something rather than you must weigh the evidence very carefully and
then make your judgement.
JOHNSON: One mistake was that in the mid-2000s the small company
rated corporation tax was reduced to zero percent. Now that sounds like
an excellent policy, but the actual impact was that enormous numbers
of people who were previously self-employed suddenly turned into
small companies and stopped paying tax. Now this was entirely
predictable ex ante - it’s exactly what happened and it was changed
relatively fast - but it was a pretty difficult process that officials had to
go through to persuade the politicians to take that sort of u-turn.
BLASTLAND: Paul Johnson. Fidgety, impatient, ideologically and
ego-driven in spite of evidence, resistant to correction, the portrait of
political decisions is not flattering – and can be exaggerated. Much of
the less visible work of government, says David Halpern, is slow,
careful and scrupulous. But not enough. What can be done? My
colleague Tim Harford, from Radio 4’s More or Less, suggests an
annual prize to the politician who makes the most constructive
admission of error. I’d go for that, in a magazine called ‘Political
Clues’, perhaps. We’re also going to take a closer look at two other
walks of life, both with plenty to lose from failure, to see if they can
help. Back to flying, then, and first to medicine. Atul Gawande is a
surgeon, writer and Associate Professor at the Harvard School of Public
Health.
GAWANDE: I’ve been obsessed with failure. (laughs) Not least
because I started writing as I was trying to learn how to do this thing
called surgery where you’re promising to cut people open and say
they’re going to be better for it. And what I was attracted to was that
surgeons were people who had great confidence in their abilities while
also recognising that their abilities were imperfect. They were
constantly grappling with the reality that in some subset of their
patients things went wrong, and they had to both have the confidence to
go ahead and take action even though sometimes it would go wrong;
and then they had to cope with the reality that they’d caused harm.
BLASTLAND: There’s a scene in the hospital drama Scrubs, which I
believe owes something to your writing, where the main character
played by Zac Ephron wanders around doing his rounds in the last
scene of a show with a ghost looking over his shoulder, and this is the
ghost of a patient who died as a result of one of his mistakes. Do we
want ghosts at people’s shoulders?
GAWANDE: I’ve got several of them who travel with me, and we do.
You are troubled by any doctor who does not have them. And also we
will not get rid of them.
BLASTLAND: How are the ghosts supposed to feel (laughing) about
the fact that they are necessary?
GAWANDE: You know the striking thing is that they are eventually
ones that we can diminish. They are part of how we learn, but we can
learn from the ghosts’ past rather than constantly generating the new
ghosts that will be our personal education.
BLASTLAND: My problem really is that patients as a whole are in a
pretty uncomfortable bargain here because they know that in order to
educate you, we have to incur a collective risk. We have to say that
your inexperience requires my jeopardy.
GAWANDE: Yeah, the interesting thing is that in my writing I try to be
honest about the fallibility of medicine, and what the fallibility boils
down to is the fact that the person who takes care of you is an imperfect
human being, that we’re all flawed and that we have areas where we
will not always know everything we’re supposed to know. But, also,
that we are more likely to trust in the people who are working with us if
we understand that they’re actually recognising that there are the
possibilities of failure, that they are taking them not just seriously but as
a kind of scientific matter; that they are looking for the patterns and
working to reduce them. The confidence that people have does not have
to come from pretending to people that we are gods.
RAF Cranwell audio
OK, Keith that was your fly 2 stalling exercise today then. And the first
one was the fully developed clean stall so how would you fly that
differently if you were to fly in the future.
Erm – the stall went OK, I was happy with that...
BLASTLAND: Who makes mistakes?
BRAILSFORD: Humans make mistakes.
BLASTLAND: That simple?! It’s not a question of bad character, bad
judgement?
BRAILSFORD: In some cases there may be bad judgement, in some
cases there may be character issues, but on the whole humans in perfect
laboratory conditions can make mistakes and it’s up to us to recognise
that there is mistakes in everybody and it’s a human condition. And
therefore if we can catalogue the errors and look for trends, what we’re
trying to do I mitigate every area where those mistakes could be made
to make it a risk-free environment.
BLASTLAND: I imagine there’s a bit of ego in flying. Is it easy to cut
through that to get to the expressions of humility that you need to
persuade people to admit their errors.
BRAILSFORD: I think that the culture that we have in the Air Force
encourages humility, admission of errors and actually reporting and
feeding back so that we can improve our game.
BLASTLAND: Simon Brailsford.
RAF Cranwell audio
Starting at pre – start checks. Start clearances of telegrams – power: off,
battery: on...PC vaults...
Noise. Cockpit checklist.
BLASTLAND: The checklist, here in the cockpit, and an idea borrowed
by Atul Gawande in his latest book as a humble but effective guard
against errors that arise from complexity in medicine. Individuals fail,
he says, but often for a systemic reason.
GAWANDE: I asked some of the top surgeons at Harvard that I most
admire to tell me about their most recent mistakes and every single one
of them had an example to tell me just from the previous few months.
As terrible as some of these failures can be - I mean these sometimes
kill people - holding people accountable is not a matter of punishment.
We do want people to accept responsibility. We expect them to learn
from the situation and to see the patterns and make sure it doesn’t
happen again. We also expect that, you know, if we’ve really ruined
someone’s life, we might even in certain situations have to take
financial responsibility. But to scapegoat, to say that their career should
end is generally to miss the entire point and the opportunity to
recognise that this was not the failure of just that person; that you in
their shoes would have been very likely to have made the same mistake
as well.
BLASTLAND: The same things crop up: the inevitability of error; the
value of the simple checklist; the need for scrutiny, from even the
lowest rank, like the nurse who prevented a surgeon, scalpel poised,
from replacing a hip joint on the wrong leg, or the rookie airman given
an award for challenging the performance of a senior instructor. Above
all, words like ‘trends’ or ‘patterns’ recur. Most of us have known
someone who was simply in the wrong job. But when different people
do the same wrong things, Atul Gawande tells us, then to see mistakes
squarely, we often need to see past the individual. Horrible, fatal errors
are still all too present in medicine and the RAF. But in both, some are
attempting to change error from a prickly, personal subject to one that
has the system in mind as much as the individual. This points to a
philosophical difference about how we attribute blame, related to a
problem known as moral luck.
WOLFF: The term ‘moral luck’ was coined by Bernard Williams, the
British philosopher, to refer to the whole range of ways in which luck -
that is to say things that are outside of our control - affects the moral
quality or moral character of our lives.
BLASTLAND: Susan Wolff. Professor of Philosophy at the University
of North Carolina.
WOLFF: So there’s a whole variety of ways in which, that happens.
One kind of case is luck in the circumstances one finds oneself in,
maybe even the circumstances one’s born into. So if you happen to be
born in 1920 in Germany, you as a result are going to find yourself
faced with choices perhaps for heroism or for complicity with horrible
evil that someone born at the same time in the United States wouldn’t
have to deal with. The kind of case that I find most gripping, and I think
most philosophers have been most concerned about, has to do with luck
in the way your actions turn out or your inactions turn out. So, imagine
one truck driver who drives somewhat recklessly, a child runs into the
street and is killed partly as a result of the reckless driving. At the same
time, think of another truck driver driving equally recklessly, but no-
one runs into the street, so he gets to his destination and nothing’s
happened. There was a bit of reckless driving, but no harm done. The
moral repercussions of who you are, what people think of you, how
people treat you is obviously tremendously different in these two cases,
but in some sense their faultiness is exactly the same. So that’s luck in
how things turn out, and that’s I think the most troubling case of moral
luck.
BLASTLAND: Susan Wolff. That judgement and blame often attach to
the unlucky is not a plea for absolution of all political mistakes. It could
be reason to spread blame more widely – to the lucky, but culpable, for
example. But it does encourage us to look beyond immediate events
and, particularly, beyond reactive assumptions about individual
character or judgement. Back to politics, what can we usefully say if we
try to see it afresh with these lessons from elsewhere? The first
suggestion, from David Halpern, the former senior civil servant who set
up a new Institute for Government, is for the sort of shift of focus
implied by that talk of patterns and trends, and the insight offered by
moral luck.
HALPERN: Well in general in life, we over attribute causes to
individual factors, and we underestimate the situational. That’s
something we do time and time again. So we think Jeremy Paxman is
terribly clever because he’s asking the question – it’s easier to ask the
questions than it is to give the answers but we then overestimate, as it
were, the personal factors - what’s been going on - as opposed to the
situational factors. So do I think that policy mistakes have all been
rooted in terribly bad individual judgements? Well of course individual
judgements are involved, but we build government not on the basis of
only you know around it being populated with Einsteins and Mother
Teresas, but on the basis it’s populated with ordinary people in essence
and we create institutions which make rational and good judgements
over time. So that’s where we should certainly focus some of our effort.
BLASTLAND: Thinking about patterns, it is striking for example, that
two of the policy errors offered by our interviewees – individual
learning accounts and zero-rated tax for small companies – both arose
because of a failure to anticipate that there would be perverse
incentives. If these are not at the top of every policy-maker’s failure
checklist, they ought to be. We’ll think more about how that shift of
focus could be achieved in a moment. A second proposal comes from
Paul Johnson, the former senior advisor.
JOHNSON: One of the interesting questions actually is whether there’s
just too much policy. It sounds like a slightly odd thing to say, but the
amount of individual initiatives that any individual department does in a
year - whether you measure that through legislation or whether you
measure it through changes that can be put through without legislation -
is enormous and has been growing over time. That of course increases
the risk of mistakes not unrelated to the fact there are large numbers of
ministers and junior ministers in departments who make their name by
putting their name behind a particular policy or change, and just the
sheer quantity creates more mistakes and more cost. Politically you
know that would take a big change in the way that government thinks
or that politicians think about their own careers and about the role that
they’re playing and that would be real central leadership from a prime
minister and chancellor to achieve.
BLASTLAND: Could you imagine it?
JOHNSON: I could imagine it if you have that strong sort of lead. I
mean …
BLASTLAND: Could you imagine any politician stepping forward and
showing that kind of lead (Johnson laughs) saying we’re coming to
power and we’re going to do a lot less?
JOHNSON: It would require a change in the nature of the political
debate and a very clear behaviour on the part of the Prime Minister,
which actually involved you know promoting ministers who didn’t do
very much (laughs) which er...people... ministers respond to what they
see happening - if they see their colleagues who are getting their names
up in lights because they’re doing 6 different policies in a year being
promoted then they’re going to carry on doing the same things so it’s a
difficult thing to imagine – it’s not conceptually impossible but I think a
brave prime minister could implement it.
BLASTLAND: Paul Johnson, now free of the machinery of
government. His suggestion that it is often wrecked by over-ambition is
supported by Estelle Morris, the former Cabinet minister. She describes
a fatal complicity of politicians and electorate that damns policy with
unrealistic expectations.
MORRIS: The public have a right to expect a lot of their politicians and
of the political process. They’re promised a lot at the election very
often and politicians speak in the language of certainty and absolutism.
Therefore people have a right to believe it. So we fence ourselves in.
Politicians say “This policy will work” and speak in the absolute terms.
If you set your stall out for this policy - we’ll transform the world and
we’ll give better life changes to every single child in every classroom in
this country - you’re promising 100% success. And when, therefore, it
doesn’t work but it works for 60% of children or 60% of patients,
politicians then want to say, “But, look, there has been partial success.”
And that, understandably, isn’t allowed; nor should be allowed. (MB
tries to interject) And we shouldn’t do it, we shouldn’t do it because it
actually plucks failure out of success.
BLASTLAND: If a small step forward is damned for not being a big
one, perhaps we’re taking too much delight in failure? Have you potted
the mistake in this programme, yet? Let’s return to the problem of
systems, identified by just about everyone here. Less colourful, less
easy to portray as hero or villain, but perhaps more dangerous. Military
failures are well studied, business failure almost a genre. In making this
programme we asked a number of people about the study of patterns of
error in politics. There isn’t any, they said. So we invited Estelle Morris
to reflect on politicians’ most significant and repeated failure from her
own experience of government.
MORRIS: What they don’t do is to say we’ve got a problem with
families who can’t support their children at home. What does the
research tell us about what we know so far that we can build on? It
doesn’t start from there because it doesn’t trust the research and
sometimes the research isn’t trustworthy. Never assume that all
research can be relied on. What it does is it starts from a different
viewpoint with instinctively this should work, or ideologically this
should work. Or even more so, I visited a school six months ago and
that worked for them. We’ll make that a national policy. So that’s
where the weakness is, I think, in looking at evidence to make a
decision to begin with about what should guide your policy, but I don’t
think they’re bad at evaluating the policies once they’ve got them
going. I think the next … if you like the third phase of that is what do
you do with the evaluation once you’ve got it? And that varies… And I
would think on reflection from my own time in government that that is
a real weak link at the moment. That link between policymaking and
research, I think is probably one of the weakest links in the whole of the
educational establishment.
HALPERN: You know I’ve spent my life doing evidence-based policy
and that’s what I did in government, so obviously I feel there’s room
for doing even better evidence based policy.
BLASTLAND: David Halpern, of the Institute for Government.
HALPERN: In many areas, the reality is when you come faced with
some important issue around education or health or whatever it might
be, when you start digging below the surface and say well what is the
evidence on which to make this careful judgement as opposed to a
kneejerk one, it turns out often the evidence base is rather thin. Now
you’ve got two responses there. One is well we’ve got to make a
decision anyway, so let’s use the best evidence we can. Fine. The other
is you might is say well, you try out various different alternatives. You
do pilots, etcetera. Well that’s a lot less politically sexy as a route
forward, but it will generally lead to better policy. And that’s of course
what normal markets do. They do trial and error, and some people try
out products and nobody wants to buy that car or it’s unreliable and that
doesn’t do well in the market, and one that does expands. And is it a big
deal? I think it’s a very big deal. I mean it’s funny, we worry greatly
about you know a few MP expenses here and there - I mean rightly. On
the other hand, we might not notice that we’re spending billions on one
programme or another which actually isn’t very effective and we never
really trial the alternatives. So that as it were is a quiet scandal that you
see in policy in many areas in the world.
BLASTLAND: There’s a surprising implication here: that because we
often lack evidence of how a policy will work, because there is often
irreducible uncertainty, we need more error, not less, in order to spot
the good and weed out the bad. But there is an important difference.
These would be errors in small-scale experiments, trials and pilots,
properly evaluated and based, where possible, on good research, not a
national, hastily rolled-out New Jerusalem. At least if government fails
here, it fails with £5 million instead of 500 million. Some remember
fondly the example of Lord Carrington, Foreign secretary just before
the Falklands war, who resigned despite being, by common consent,
blameless. The virtue of sacrificing able people for the sake of a
purification ritual is not obvious to me. It was noble of Lord Carrington,
but a waste for the rest of us. These days, of course, resignation can be
a revolving door: in, out, in, out. But it’s hard to avoid the conclusion
that politicians invite a greater risk of exit than necessary, their biggest
mistake being a failure to address the systemic origins of bad policy.
Fraser Nelson of the Spectator has one more suggestion.
NELSON: Get into the habits of saying well I’m going to be the sort of
guy who corrects mistakes. I remember before Ken Livingstone was
elected Mayor of London and he was proposing the congestion charge.
Somebody asked him, “If it’s a mistake, what will you do?” He said, “If
it doesn’t work, I’m going to say I’m sorry and I’ll scrap it.” Now that
was music to my ears. It made me more inclined to vote for him. I
thought this is what you want to hear - a politician who says yes, I’m
going to try it. It might work. It might not. If it doesn’t, I’ll apologise
and I’ll scrap it. Now I think people would be in the market for that
type of politics.
BLASTLAND: Let me get this right: the editor of the Spectator sees the
appeal of Ken Livingstone because he talks about making mistakes. Is
he right that there’s a market for that type of politics? Have we also
grown weary of promises of the New Jerusalem? If so, lowered
expectations create space for more modest, but perhaps more thoughtful
policy. Even medicine, says Atul Gawande, is still often ignorant of its
efficacy. It fails to count its ghosts properly or understand why too
many keep on coming. Politics seems worse. We don’t want to
encourage an attitude of: it weren’t me gov, I blame the system. But at
the moment the system often gets away with it, only to re-offend. More
awareness of the patterns of error would help, so too a thirst for
evidence. These are not panaceas, and values or the ends to which
policy aspires still matter more. But when the clamour goes up for a
resignation because the policy wasn’t piloted, or trialled and evaluated
properly, or that perverse incentives were not spotted, then we’ll know
we’re some way towards failing better. Our own mistake? I named the
wrong actor in that hospital drama. So sack me.
END OF TRANSCRIPT